Provider Demographics
NPI:1437144938
Name:PRUITT, MARK A (FNP)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:A
Last Name:PRUITT
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 DOCTORS PARK
Mailing Address - Street 2:
Mailing Address - City:GALAX
Mailing Address - State:VA
Mailing Address - Zip Code:24333-2277
Mailing Address - Country:US
Mailing Address - Phone:276-595-8921
Mailing Address - Fax:276-883-6232
Practice Address - Street 1:101 DOCTORS PARK
Practice Address - Street 2:
Practice Address - City:GALAX
Practice Address - State:VA
Practice Address - Zip Code:24333-2277
Practice Address - Country:US
Practice Address - Phone:541-632-4050
Practice Address - Fax:276-883-6232
Is Sole Proprietor?:No
Enumeration Date:2005-09-12
Last Update Date:2025-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024178316363L00000X
TN7012363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3902626Medicaid
TN3902628Medicare ID - Type Unspecified
TNS80978Medicare UPIN